Medicare Part A and Part B Coverage Limitations: What to Expect

Enrolling in Medicare is an excellent way to ensure you are able to receive the vital health care you may need.  However, not all medical supplies and services will be covered by your Medicare Parts A and B.  In order to best prepare for your future, it is essential to be aware of some important coverage limitations.

For instance, Medicare doesn’t cover acupuncture, cosmetic surgery, hearing aids, hearing aid-fitting exams, and hearing tests (unless ordered by your doctor).  Medicare also won’t cover custodial care, unless you are also receiving skilled nursing care in a nursing facility, in a hospice, or at home. The majority of chiropractic services also aren’t covered, other than for subluxation.  Aside from a few exceptions, most dental care, dentures, foot care, orthopedic shoes, and eye-glasses won’t be covered either.

Although Medicare does cover a “welcome to Medicare” physical exam when you first enroll, yearly or routine exams aren’t generally covered.  Additionally, many vaccines and prescription drugs, as well as syringes or insulin not used with an insulin pump, won’t be covered by Parts A and B. If you plan to travel, be aware that most medical care won’t be covered by Medicare if you’re traveling outside of the United States. 

There are, of course, many valuable services which are covered by your Medicare Parts A and B.  Even when services are covered, though, you may be responsible for paying deductibles, coinsurance, or copayments for a number of these services.  By being cognizant of coverage limitations in services and supplies, you will be better able to plan, financially and practically, for your health care needs.

Costs and Coverage of Medicare Part A

Medicare Part A is the component of your Medicare insurance that deals with Hospital Insurance.  For most people, there is no monthly premium for Medicare Part A, as long as you or your spouse have paid enough Medicare taxes while working.   However, while you usually don’t need to pay monthly premiums for Part A, many services will involve some out-of-pocket costs. 

Receiving blood in the Original Medicare Plan, for example, will require you to pay for the first 3 pints you get as an inpatient.  After that, you will be responsible for 20% of the Medicare-approved amount.  An exception to this cost is if you or someone else donates enough blood to replace the blood you received. 

For home health care, you pay nothing for the home health care services and 20% of the Medicare-approved amount for necessary durable medical equipment.  For hospice care, you will need to cover a copayment of up to $5.00 per prescription for outpatient prescription drugs, as well as 5% of the Medicare-approved amount for inpatient respite care.  Also, if you receive hospice care somewhere other than for short-term general inpatient/respite care, you might be responsible for the cost of room and board.

In the case of hospital stays, you will need to pay a $1024 deductible and $0 coinsurance for 1 – 60 days each benefit period.  For days 61 – 90 each benefit period, you will cover $256.  Following day 90 for each benefit period (for up to 60 days over your lifetime), you will pay $512 per lifetime reserve day.

For skilled nursing facility stays, you will pay nothing for the first 20 days each benefit period, and $128 per day for days 21 – 100.  After that, you will be responsible for all costs incurred. 

Medicare Advantage Plans will cover the same benefits as your Original Medicare, but costs won’t necessarily be the same.  For details on specific out-of-pocket costs, contact your plan directly.

 

Drug Coverage: Some Important Rules You Should Know

All Medicare Prescription Drug plans have a number of rules, created to meet the needs of beneficiaries and, at the same time, to protect plan providers.  

 One of the rules for most Medicare drug plans is that they need to cover two drugs, minimally, in each drug category. They also need to cover almost all drugs in the anit-psychotics, anit-depressants, anti-convulsants, immunosuppressants, cancer, and HIV/AIDS classes.  Additionally, even when a Medicare drug plan doesn’t have a certain drug on its formulary, another drug with a comparable function which is equally effective will likely be covered.

The plans are usually able to choose which of the drugs in each category they will cover.  There are also a number of drugs your plan probably won’t cover, like barbiturates, benzodiazepines, and weight control drugs, although some plans may.  Most often, your drug plan won’t cover over-the-counter medication.  There are, of course, exceptions, like if your state allows people with Medicaid to receive coverage for these over-the-counter drugs.

Plans must, regardless of which Medicare Prescription Drug plan you are enrolled in, have some sort of a process which allows you to request coverage for a necessary drug not included in their formulary.

Drug plans also have some stipulations to ensure correct coverage use, such as you and/or your doctor needing to contact the plan prior to prescription coverage, demonstration of the medical necessity of the drug, a limit on how many drugs you can get at once, and “step therapy”, which is trying one or more similar, low-cost drug before moving on to a more expensive brand-name version. 

Because formularies vary according to plan and because they may change, each plan will have the required up-to-date information you need.  To find out what drugs are covered by your Medicare Drug Plan, contact your plan directly. 

The Flu Shot: An Important Preventive Service

The Flu Shot is covered each flu season for all beneficiaries in a Medicare program.  It is given once a year, either in the fall or in the winter, and is an important factor in staying healthy. 

The flu, or influenza, is a contagious infection which is commonly spread though coughing, sneezing, or direct contact.    It can cause a number of symptoms, ranging from congestion and a sore throat, to muscle pain and fatigue, to fever and chills, to, albeit  rarely, nausea and diarrhea. Some people will have only a few symptoms, others will have many.

Although the flu shot won’t necessarily prevent you from getting the flu, your symptoms will likely be milder if you’ve had your vaccine. It’s a good idea to get your shot between September and November, since December is when the flu begins to gain prominence.  However, because flu season is considered to be from November to April, you should get your flu shot even if you missed the fall vaccination.  

In addition to getting a flu shot, you can take other steps to help prevent the spread of influenza.  Wash your hands often, with soap and water.  Try not to frequently touch your mouth or nose. If possible, try not to be in close contact with others who have the flu.  If you are sick yourself, stay home from work and keep your distance from people, when possible. Also, make sure you cover your mouth when coughing or sneezing. 

Medicare covers a number of essential preventive services, including the Flu Shot. Make the most out of your coverage: remember to get your flu shot each year.

The Recovery Audit Contractor Demonstration Program

The Recovery Audit Contractor demonstration program was created to study whether or not using Recovery Audit Contractors is a productive way to make sure correct payments are being made by Medicare to providers, and whether or not this method will save Medicare money and further protect the Medicare Trust Fund.

Recovery Audit Contractors, or RAC, are companies hired by Medicare to find incorrect payments made by Medicare to health care providers and suppliers. Incorrect payments can, of course, come in a number of forms, including claims erroneously submitted and paid twice as well as, sometimes, underpayments by Medicare. The RAC program will catch and correct both, although it is ultimately intended to help Medicare by recovering money lost by overpayments.

While you may get your money back if a RAC review finds you personally overpaid, the Recovery Audit Contractor Program will not put any other money directly back into your pockets. Even if RAC companies are able to recover lost funds for Medicare, this money won’t be shared directly with beneficiaries. Your Medicare benefits also will not change due to the RAC program.

However, the RAC program does benefit you indirectly. For instance, it saves taxpayer dollars. It also protects the Medicare Trust Funds, which will help future generations as well.

Currently, the Medicare RAC program is in California, Florida, New York, Massachusetts, South Caroline, and Arizona. The Centers for Medicare & Medicaid Services expect RAC to be in use throughout the country by 2010.

Medicare’s Hospital Compare

The Centers for Medicare and Medicaid Services provide an online resource intended to help you make informed choices about your health care.  The resource, called Hospital Compare, offers a variety of specific information in order to give you a complete picture of hospitals throughout the country. 

The Hospital Compare site allows you to compare hospitals in a number of different ways.  For instance, it will enable you to see, using survey information, how patients feel about their hospital experiences.  Some topics include pain management, overall quality of care, and staff communication with patients. 

The site also lets you look at how mortality rates for different conditions compare with the national death rates for these same conditions, and how often hospitals treat recommended heart attacks, heart failure, pneumonia, and surgery.  

You can compare hospitals in terms of how many people with Medicare have had various treatments.  You can even see what Medicare usually pays a hospital when it performs certain procedures. 

In addition, you may use the Hospital Compare site to figure out which hospitals are accredited.  The Hospital Compare site will also provide information on your rights as a patient and how to report a quality complaint.   It can direct to you other relevant publications or websites.

By using the Hospital Compare resource, you will be able to make an educated decision regarding which hospitals will likely offer you the highest quality of care.  You can find this valuable tool at www.medicare.gov/hospital.

An Introduction to Programs of All-inclusive Care for the Elderly

Programs of All-inclusive Care for the Elderly, otherwise known as PACE, are Medicare programs for individuals over 55 who have disabilities.  PACE provides alternatives to nursing-home care, and, through a variety of services, works to offer beneficiaries with options to remain living in their community.   You are eligible for PACE if you are 55 years or older, live in a PACE organization service area, are certified by your state as needing nursing home level of care, and are able to, with the help of PACE, safely reside in your community when you join.

To create an individualized health care plan, PACE uses a team of skilled professionals, experienced in working with the elderly.  This health care team will work with you to determine the type of care and services you will require to have your health needs met. 

PACE covers a wide variety of services, in addition to those covered by Medicare and Medicaid.  Some of their coverage benefits may include prescription medication, hospital visits, check-ups, doctor care, home care, emergency services, transportation, necessary nursing home stays, adult day care, recreational therapy, social services, dentist care, nutritional counseling, and X-ray services.  There are a number of other services that may be covered as well, depending on your needs. 

Enrollment in PACE is does not depend on your financial situation.  If you qualify for Medicare, all Medicare-covered services will be paid for.  The long-term care offered by PACE will also be covered, either fully or with a minimal monthly payment, if you qualify for your State’s Medicaid Program.  If you don’t, you will need to pay a monthly premium for PACE benefits and Medicare Prescription Drug coverage, although you won’t need to pay any deductibles or copayments for services approved by your team. 

 PACE is one way Medicare can meet your needs.  For more information, visit the National PACE Association at www.npaonline.org.

Medicare Provides Information on Dialysis Facilities

If you or someone you love needs regular dialysis, uniform information about available dialysis facilities is invaluable.  It’s important to be able to compare your options and to be aware of the quality of care at the facilities you consider. 

Fortunately, Medicare provides an easy, effective way for you to compare dialysis facilities through their website, with their “Dialysis Facility Compare Tool”.  This tool allows users to access valuable information about specific dialysis treatment facilities.  The tool provides basic information about the facility name, address, and telephone number.  It also offers the date Medicare certified the facility, shifts beginning at or after 5:00pm, the number of hemodialysis treatment stations, the types of dialysis available, the organization that owns/manages the facility, and whether or not the facility is non-profit.  In terms of quality measures, you can find out the percentage of patients at specific facilities who got adequate hemodialysis, who were treated for anemia, and whose anemia was adequately managed. You can find out patient survival information and, ultimately, how well the facility treats its patients.

The compare tool will allow you to search for dialysis facilities by name, city, ZIP code, state, or country.  Once you select some facilities you would like to compare, you will have access to the dialysis facility services and quality information.  You will also be given contact information for local ESRD Networks and State Survey Agencies, which you can use to get more information about dialysis. 

The compare tool will also provide additional resources, such as informational pamphlets, answers to frequently asked questions, definitions of relevant terms, information on complaint procedures, information on patient rights, a patient checklist, and links to other related websites.

You can access Medicare’s Dialysis Facility Compare tool at www.medicare.gov. 

A Right to Know: An Overview of the Original Medicare Appeal Process

If you are enrolled in a Medicare plan, you automatically have a number of rights.  One of the most essential rights is the right to appeal.  The right to appeal (a complaint you make when you disagree with a decision made by your Medicare plan), is guaranteed to all Medicare recipients.

Some conditions under which you may choose to file an appeal are, for instance, if you are denied coverage for care you’ve already received, if you are denied a request for a service, supply, or prescription (or if it is not covered and you think it should be), or if your plan stops paying for a service you are currently getting coverage for.

If you decide to file an appeal, how to proceed depends on what type of plan you are enrolled in.  Medicare Advantage Plans and Prescription Drug Plans have specific procedures in place to allow you to use the appeal process.  They should include this information in the materials you receive from them. Similarly, Original Medicare also has specific procedures in appealing a decision. 

The first step in the Original Medicare Plan is to obtain the Medicare Summary Notice where the service you are appealing appears.  Next, you need to circle the item to which you object.  You then need to explain, in written form, why you disagree.  You will want to write this explanation on the MSN. Include your telephone number and signature.  Finally, send it (or a copy) to the address in the “Appeals Information” section of the MSN.  You need to file this appeal within 120 days of when you receive the MSN. 

It’s essential, when considering filing an appeal, to follow the instructions on your MSN.  There are also a number of resources to help you with this process.  Call your State Health Insurance Assistance Program for more information, or 1-800-MEDICARE. 

Receiving Earlier ESRD Medicare Coverage

Medicare provides health insurance for people 65 and over, people under 65 with specific disabilities, and people of any age with End-Stage Renal Disease. Both Medicare Parts A and B are required to provide ESRD Medicare recipients with coverage.

 Typically, dialysis coverage begins the fourth month of your treatments.  However, there are some circumstances which will allow you to receive earlier Medicare benefits. For instance, if you participate in a home dialysis training program to learn how to give yourself home dialysis  treatments (before your fourth month of treatments), your coverage can begin the first month of dialysis, provided the training facility is approved by Medicare and that you expect to finish the training and give yourself dialysis treatments.  You can receive coverage the same month you are admitted to a hospital (also approved by Medicare) for a kidney transplant or preparations for a kidney transplant, if your transplant is within that month or two months following it.  If your transplant is postponed over two months after being admitted, your coverage can start two months before your transplant.   

Although your coverage will end twelve months after the month you stop dialysis treatments and 36 months after the month of your kidney transplant, there are circumstances which will allow your benefits to be extended.  If you get a kidney transplant 12 within months following the month when you stopped dialysis or 36 months following the month you have a kidney transplant, your benefits will be extended.  They will also be extended if you start dialysis again in the same time frame.

If you or someone you love has End-Stage Renal Disease, look into your Medicare benefits.   When you’re aware of your options, you will find that Medicare can help provide timely coverage for your health care needs.

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